This month’s Savvy Coder tackles a case of diplopia that occurred after cataract surgery. (For a case that occurred after glaucoma surgery, see “Strabismus After Glaucoma Surgery,” below)
Earlier Cataract Surgery
A 67-year-old patient underwent uneventful phacoemulsification with implantation of a monofocal intraocular lens (IOL) in her right eye. Two weeks later, she had the same procedure in her left eye. Both surgeries took place in the outpatient setting, and the patient had topical and monitored anesthesia care (MAC). She was healthy, and her only medication was lisinopril for hypertension. She had no other risks for heart disease or stroke. After her second cataract surgery, she noticed intermittent diplopia.
The physical exam. Examination revealed well-centered IOLs, clear corneas, a best-corrected visual acuity of 20/20 in each eye, and a normal fundus. Her manifest refraction was –1.00 +0.75 × 175 in the right eye and –0.75 +0.75 × 05 in the left eye. The motility exam revealed a 10-D left hypertropia at distance and near, falling to 8 D in left gaze and 10 D in right gaze, and full ductions with no evidence of oblique overaction or underaction.
Neutralizing the diplopia. With the manifest refraction in place, the diplopia at distance was neutralized with 5-D base-up prism on the right combined with 5-D base-down prism on the left. And a 2.75-D add along with the 10 D of vertical prism neutralized the diplopia at near.
Next steps. The findings were reviewed with the patient, and the choice of eye muscle surgery or prism glasses was offered with a recommendation that glasses and prism might be a good first step to provide best vision and eliminate double vision. If she elected surgery, she would likely be a candidate for recession of 1 vertical muscle.
Partners in Same Practice
If the cataract surgery was performed by a partner at your practice, how does that impact your coding as the strabismus surgeon when you take over the patient?
Coding for the exams. You can’t bill for the exams during the cataract surgery’s global period, but you can bill for the motility exam. Do so using CPT code 92060 Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure). No modifier is necessary.
Coding for surgery. Should the patient decide on surgery, you can bill for CPT code 67314 Strabismus surgery, recession or resection procedure; 1 vertical muscle (excluding superior oblique).
You also should append 2 modifiers:
- –78, Unplanned return to the operating or procedure room by the same physician following initial procedure for a related procedure during the postoperative period. (For the purpose of this modifier, physicians in the same group practice are considered “the same physician.”)
- –LT, to indicate the left eye.
Surgical payment will be 80% of the allowable. Payment for surgical codes can be broken into 3 parts, with the pre-, intra-, and postoperative components being allocated 10%, 70%, and 20% of the allowable, respectively. When you append modifier –78, you continue the balance of the earlier surgery’s global period, rather than starting a new one. Therefore, you won’t be paid for the postop component of the second surgery.
If the Earlier Surgery Was Performed Elsewhere
If the cataract surgeon is not part of your group practice, bill the later patient encounters as follows.
Coding for the exams. All exams should be billed using the appropriate level of E&M or Eye visit code, and no modifier is necessary. You can bill for the sensorimotor exam using CPT code 92060, and no modifier is necessary.
Coding for surgery. Bill for the strabismus surgery using CPT code 67314 and append modifier –LT only (not –78). Payment is 100% of the allowable, and strabismus surgery’s 90-day global period applies.
Strabismus After Glaucoma Surgery
A 70-year-old woman with advanced glaucoma underwent placement of an Ahmed implant in the superotemporal quadrant of her left eye. Postoperatively, she developed horizontal diplopia.
Examination. During the initial evaluation for diplopia 6 months after glaucoma surgery, visual acuity was 20/20 in the right eye and 20/25 in the left. She had an arcuate scotoma in the left eye; the visual field in the right eye was full. There was a superotemporal bleb in the left eye. The intraocular pressure was 15 mm Hg in the right eye and 10 mm Hg in the left. She was bilaterally pseudophakic.
The fundus exam was normal in the right eye with a cup/disc ratio of 0.2; the left eye had an increased cup/disc ratio of 0.9. In the left eye, she had 35 prism D of exotropia in the distance and mildly limited adduction.
The surgery. The option of strabismus surgery was discussed with her. She declined to have surgery on the right eye but consented to strabismus surgery on the left eye and underwent a left lateral rectus recession with an adjustable suture and a left medial rectus resection. Careful dissection around the lateral rectus muscle allowed preservation of the bleb and fibrous capsule.
Coding tips. In a scenario such as this one, because the strabismus surgery was performed outside the global period of the initial glaucoma surgery, coding is the same whether the glaucoma specialist is part of your group practice or not.
Keep in mind the following:
- All the exams are billable with the appropriate level of E&M or Eye visit code.
- The sensorimotor exam is separately billable.
- Bill for the surgery using CPT code 67312 Strabismus surgery, recession or resection procedure; 2 horizontal muscles, and append modifier –LT. Payment is 100% of the allowable.
- Also bill CPT code 67331 Strabismus surgery on patient with previous eye surgery that did not involve the extraocular muscles and CPT code 67335 Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s). (List separately in addition to code for specific strabismus surgery). Append modifier –LT to both 67331 and 67335. As add-on codes, payment is 100% of the allowable for each.